Latest Advances regarding on Surgery. 26 Feb -3th of March 2013

Latest Advances regarding on Surgery.

American scientists from the Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, Michigan, USA have recently shown the trends in the use of images to advance women undergoing surgery for breast cancer. Evidence-based guidelines recommend perioperative diagnostic imaging limited to newly diagnosed breast cancer. For patients with age> 65 years, using conventional imaging (mammography, ultrasound and x-rays) remained stable, while the advanced imaging (computed tomography [CT] scans resonance nuclear medicine [ emission tomography / s], and magnetic scans [RM] use) has increased. In this study, the authors evaluated the use of traditional and advanced image among younger patients (age </ = 65 years) who underwent surgery for breast cancer. The MarketScan commercial claims database research finds 2005 to 2008 were analyzed to evaluate the use of conventional and advanced diagnostic imaging associated with surgery for ductal carcinoma in situ (DCIS) or stage I to III invasive breast cancer. The cohort study included 52,202 women (13% with ductal carcinoma in situ, and 87% of breast cancer in phase IIII). The proportion of patients who undergo conventional imaging techniques remained stable, while the average conventional imaging tests per patient rose from 4.21 in 2005 to 4.79 tests per patient testing 2008 (p <0.0001). For advanced images, the proportion of women who underwent images increased 48.8% in 2005 to 68.8% in 2008 (p <0.001) and the number of tests per patient (from 1.53 tests tests in 2005 to 1.98 in 2008, P <0.0001). MRI scans accounted for nearly all the increase in advanced imaging. Patients who underwent MRI examinations received much more traditional imaging tests compared with those who did not, indicating that these tests are additive and not replace traditional image. The present results demonstrate that use of peri-operative breast MRI has increased among women aged <65 years. The study further indicated to determine whether the benefits of this procedure justify greater use.


American scientists and physicians from the Department of Bioengineering, University of California San Diego, 9500 Gilman Drive MC: 0412, La Jolla have recently shown the in vivo efficacy of allografts osteocondrals fresh frozen goat before 6 months associated with PRG4 secretion. The long-term efficacy of allografts osteocondrals is due to the presence of viable chondrocytes in the cartilage graft. Chondrocyte allografts in osteocondrals, especially the articular surface that normally produce lubricating proteoglycan4 (PRG4), are susceptible to death storageassociated. The hypothesis of this study is that the loss of chondrocytes within osteocondrals grafts leads to a decrease in the secretion of PRG4, after storage and subsequent implantation of the graft. The objectives were to determine the effect of treatment with allograft osteocondral (vs FROZEN FRESH) on the secretion of PRG4 functional after (i) storage, and (ii) 6 months in vivo in adult goats. Frozen storage reduces allograft cartilage PRG4 secretion by approximately 85% compared to the fresh allograft storage. After 6 months in vivo function for allografts PRG4secreting osteocondrals dropped frozen prior to storage by approximately 81% compared to fresh allografts by about 84% versus non-operated control cartilage. Also, the cellularity in articular surface in frozen allografts was approximately 96% lower than fresh allografts and operated cartilage. Thus, the function of allografts seems PRG4secreting maintained in vivo based on their state after storage. PRG4 secretion may be a useful marker not only the profitability of the allograft, but also a biological process that protects the articular surface grafts after repair of cartilage.


Chinese scientists from the Department of Anesthesiology, Fudan University Shanghai Cancer Center, Shanghai, China have recently shown the effect of penehyclidine hydrochloride on the incidence of intraoperative awakening in Chinese patients undergoing breast cancer surgery during general anesthesia. Intraoperative awakening can lead to serious adverse psychological consequences. They performed a prospective, randomized doubleblinded in 920 patients undergoing surgery for breast cancer biespectral indexguided intravenous anesthesia to evaluate the effect of intraoperative awakening penehyclidine hydrochloride. The patients were divided at random to receive 0.01 (1) penehyclidine hydrochloride or saline intravenously 30 minutes before surgery. The preadministración, levels of preoperative anxiety was assessed using a visual analogue scale of 100 mm. Awakening was defined as intraoperative memory of intraoperative events using a modified Brice interview administered 26 hours after the operation, and the next 2448 h. A committee of three experts, blind to the conditions of the study were analyzed independently reported all the memories. No differences were found in the depth of anesthesia and preoperative anxiety levels of patients between the two groups. The incidence of awareness penehyclidine hydrochloride (patients 0/456, 0%) was significantly lower than with saline (5/452, 1.1%), p = 0.030. They conclude that penehyclidine hydrochloride reduced the incidence of intraoperative awakening in patients undergoing breast cancer surgery during general anesthesia.


Chinese scientists and physicians from the Department of Surgery, Shanghai Public Health Center Affiliated Clinical Fudan University, 2901 Caolang Road, Jinshan District, Shanghai 201508, China have recently shown the preoperative risk factors that influence the incidence of postoperative sepsis in patients infected with human immunodeficiency virus. Compared with patients infected with human immunodeficiency virus (HIV) infected patients undergoing surgery have a higher risk of developing postoperative sepsis. The aim was to investigate preoperative risk factors that affect the incidence of sepsis after surgery in patients infected with HIV. The clinical data of 215 patients with HIV / acquired immunodeficiency syndrome (AIDS) who had undergone surgery between January 2011 and February 2012 retrospectively examined the impact of HIV / AIDS, the incidence of postoperative sepsis. Logistic regression analysis identified four independent risk factors of postoperative sepsis in patients infected with HIV: CD4 [B = 0.007, odds ratio (OR) 993], the levels of albumin in the blood ( B = 0.077, OR 0926), surgical infection (B = 1.887 or 6.598), surgery (B = 1.013, OR 2754). The incidence of postoperative sepsis was highest with CD4 <100 cells / = / multilateral levels, albumin <35 g / L, the presence of surgical infection, the patient had undergone major surgery81.25% 39 / 48, 76.47%, 26/34, 70.73%, 29/41, and 54.76%, 46/84, respectively, compared to the total cohort (40.93%, 88/215) . When CD4 counts were> 350 cells / Mul, the incidence of postoperative sepsis was significantly lower (16.36%, 9/55). Low counts of CD4 cells, hypoalbuminemia, surgery and surgical infection are independent risk factors for the development of postoperative sepsis in patients infected with HIV. Number of CD4 cells and albumin levels negatively correlated with the incidence of postoperative sepsis, whereas surgical infections and major surgical procedures positively correlated with the incidence of postoperative sepsis.


Swedish scientists from the Upper Gastrointestinal Research Unit, Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden have recently shown that the influence of surgical factors persistent symptoms 3 years after surgery of esophageal cancer. A population-based study in Sweden. Little is known about the long-term effects of surgical approach and type of anastomosis in the surgical treatment of esophageal cancer in the results patientreported. A Swedish study nationwide, population-based cohort included patients undergoing esophagectomy for esophageal cancer in 20012005. The exhibits included pre-surgical approach (transthoracic or Transhiatal) and the technique of the anastomosis (sutured manually or mechanically). The results were esophagealspecific symptoms 3 years after surgery. Symptoms were measured using the questionnaire of quality of life cancerspecific the QLQC30, supplemented by module cancerspecific esophagus (QLQOES18), both developed by the European Organization for Research and Treatment of Cancer. Logistic regression models were used to estimate relative risks, expressed as odds ratios (OR) with 95% confidence intervals (CI) experience symptoms as assessed from questionnaires. Of 178 patients included, there was a turnout of 84%. There were no statistically significant differences regarding surgical approach. However, the point estimates indicate that patients operated with a focus Transhiatal had a lower risk for symptoms of nausea and vomiting (OR = 0.5, 95% CI 0.11.9), diarrhea (OR = 0.5 95% CI: 0.21.8) and difficulty swallowing (OR = 0.4, 95% CI: 03), and a slightly greater risk of loss of appetite (OR = 2, 95% CI 0.75.6) compared with patients operated with transthoracic approach. Anastomotic technique does not change the risk for any of the selected symptoms. The surgical approach and type of anastomosis did not seem to influence the risk of cancer and general symptoms esophagealspecific 3 years after surgery for esophageal cancer.


South korean scientists and physicians from the Division of Gastrointestinal Surgery, Department of Surgery, Seoul St. Mary Hospital, Faculty of Medicine, Catholic University of Korea, Seoul, Korea have recently shown the role of preoperative colonoscopy in patients with gastric cancer. A case-control study of the prevalence of colorectal neoplasia coexistence. They evaluated the prevalence of coexistence of asymptomatic colorectal neoplasia (CRN) in patients with gastric cancer (GC). Preoperative colonoscopy examinations were performed in 495 patients with gastric cancer underwent gastrectomy between January 2009 and December 2010. Compare the prevalence of CRN to these patients as well as in a normal population, they selected 495 people agematched sex and underwent colonoscopy for the detection of health. Risk factors for CRN were evaluated by univariate and multivariate analysis. The overall incidence of CRN was 41.8% (414/990). The prevalence of CRN, CRN high risk, and colorectal carcinoma (CRC) were significantly higher in GC than in the control group (CRN global: 48.9% versus 34.7%, high risk CRN: 28, 3% to 13.5%; CRC: 2.6% versus 0.2%, all P <0.001). The presence of GC [odds ratio (OR) 1.82, 95% confidence interval (CI), 1:42:38, p <0.001], age> / = 50 years (OR 2.58, 95% CI, 1.753.81 P <0.001) and male sex (OR 2.28, 95% CI 1.723.02, p <0.001) were risk factors for all CCC. In patients with GC, aged> / = 40 years (OR = 3.22, 95% CI 1.248.37, p = 0.016) and male sex (OR 3.21, 95% CI 2.174.76, p <0.001) were risk factors for general CRN. The prevalence of coexistence of CRN, including CRC was higher in patients with GC than in the normal population. Preoperative colonoscopy is strongly indicated in patients with GC who are men and / or> / = 40 years of age.


American scientists from the Center for Surgery and Public Health, Department of Surgery, Brigham & Women Hospital, Boston, MA, USA have recently shown the variation in the use of reconstruction after mastectomy in elderly women. Regardless of age, women who choose to undergo reconstruction report after mastectomy improves quality of life as a result. However, the effective use of reconstruction decreases with age. While this may reflect the preference of the patient and clinical factors, may also represent agebased disparity. Women aged 65 years or older who underwent mastectomy for ductal carcinoma in situ / stage I / II breast cancer (20002005) were identified in the database SEERMedicare. The overall rates and institutional reconstruction was calculated. Characteristics of hospitals with higher and lower rates of reconstruction were compared. PseudoR (2) statistics using a logistic regression model patientlevel estimated the relative contribution of the actors of the institution and the patient. A total of 19,234 patients in 716 institutions were examined. Overall, 6% of elderly patients received reconstruction after mastectomy. Institutional rates ranged from zero to> 40%. Considering that 53% of institutions made any reconstruction in elderly patients, 5.6% reconstructions performed in 20%. Although the characteristics of the patient (% delta (2) = 70%), particularly age (% delta (2) = 34%) were the main determinants of rebuilding institutional characteristics also partly explains variation (% delta (2) = 16%). This suggests that, in addition to the appropriate factors, including the clinical characteristics and preferences of the patient, the use of reconstruction among older women is also influenced by the institution where they receive care. The increase in the probability of reconstruction and institution suggests association with structural inequality of access to this critical component of care for breast cancer. Greater awareness of potential age difference is an important first step to improve the access of older women who are candidates for reconstruction and desire.


Indian scientists from the Institute of minimum access, Metabolic and Bariatric Surgery, Max Super Speciality Hospital, 2 Press Enclave Road, Saket, New Delhi, 110017, India have recently shown the effectiveness of Block UltrasoundGuided transverse abdominal plane after laparoscopic bariatric surgery. A double-blind, randomized and controlled. The effectiveness of ultrasoundguided transverse plane of the abdomen (USGTAP) blog as part of multimodal analgesia was assessed in morbidly obese patients undergoing laparoscopic bariatric surgery. They studied 100 patients with BMI> 35 kg / m (2). They were randomly assigned to study (USGTAP) and control groups. Pain scores at rest and in motion several time points up to 24 postoperative hours were compared. Other parameters evaluated were patients who require Tramazac hydrochloride (TMZ) as rescue medication, sedation scores, time to walk, adverse events and patient satisfaction. The mean visual analog pain scale score of the study (USGTAP) group was consistently less than 1, 3, 6, 12, and 24 hours at rest and in motion, in the postoperative period. Number of patients requiring TMZ requires in the first third and sixth hour was significantly lower in the group USGTAP. The sedative effect of the prolonged TMZ affected when walking. Patients in the control group remained more sedated. Four patients in the control group required BIPAP support after the operation, there was no adverse effect. Walking time was 6.3 + / 08/01 has USGTAP and 8 + / 1/8 h control group, p <0.001. Patient satisfaction scores were significantly higher in USGTAP, p <0.001. Their study demonstrates that USGTAP as part of multimodal analgesia technique in morbidly obese patients undergoing laparoscopic gastric bypass reduces the need for opioids, improved pain score, sedation decreases favors early ambulation, and has increased patient satisfaction.


Singaporean scientists and physicians from the Department of Oral and Maxillofacial Surgery, National Dental Centre Singapore, 5 Second Hospital Avenue, Singapore 168938, Singapore have recently shown the effect of radiotherapy on mandibular reconstruction using a modular endoprosthesis. The stent system has proven to be a potential option mandibular reconstruction. The aim of this pilot study was to test animals in vivo effects of postoperative radiation using brachytherapy on bone and soft tissue healing in mandibles reconstructed with endoprosthesis. Six adult Macaca fascicularis jaws were reconstructed with cemented prostheses after segmental resection of the body. The animals were divided into two groups. The test group was subjected to radiation therapy 1 month after surgery, whereas the control group did not receive any radiation. The results showed no major side effects of radiation. Ulceration of the mucosa and wound dehiscence broadcast sites healed in 4 weeks. One animal in each group had prosthetic failure and was unable to complete the study. MicroCT findings indicated that there was no significant difference between the percentage of total bone volume (TBV%) of the study and control groups. Histomorfomètric analysis using rating scales did not show significant differences between the two groups. Under the conditions of this study, postoperative brachytherapy did not affect the response of the tissue around the stent within the time period 6 months after radiation. The stent thus remains a viable reconstructive when postoperative radiation is prescribed.

Latest Advances on Surgery. according to Top Surgery. 12-25th February 2013

Latest Advances on Surgery:

To determine whether the integration of magnetic resonance imaging (MRI) in the differential diagnosis of right lower quadrant pain in pregnant patients is associated with improved outcomes, as measured by the negative laparotomy rate (NLR) and the perforation rate (PR ). Institutional review board approval was obtained for this retrospective review of medical records. Two hundred sixtyseven pregnant patients who underwent surgery (n = 82) or MR imaging examination (n = 217), due to suspected appendicitis between 1 January 1996 and 31 August 2011 were identified. Relevant reports of ultrasound imaging and MRI sample were classified as true positive, false positive, true negative, false negative or doubtful. Using MR images were analyzed to define preand postMR imaging cohorts. NLR and PR were calculated for both groups were compared using a Fisher’s exact test. Value of sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for the RM were calculated.FINDINGS: RM was introduced into clinical diagnostic study in 2004. From 1996 to 2003, the NLR in pregnant patients was 55% (17 of 31), and PR was 21% (three of 14). From 2004 to 2011, NLR was 29% (15 of 51), and PR was 26% (nine of 35). The decrease of 47% in the NLR ([55% 29%] / 55%) was statistically significant (P = 0.02). The change in PR was not significant (P> 0.99). The sensitivity, specificity, PPV and NPV of MRI in the diagnosis of appendicitis was 89% (17 of 19), 97% (187 of 193), 74% (17 of 23) and 99% (187 of 189), respectively.Conclusion: Incorporating routine MR imaging in the study of clinical diagnosis of suspected appendicitis in pregnant patients in this institution was associated with a decrease in the NLR of 47% without a significant change in PR.


To evaluate the association between preoperative breast magnetic resonance imaging (MRI) and the rate of utilization of multiple surgeries, and to investigate the extent of any variation between multiple surgeries doctors. We identified patients with stage 0, I, or II breast cancer diagnosed between 2002 and 2007 in the Surveillance, Epidemiology and End Results Medicare database. With the diagnosis and procedure codes, we determined that the episode had completed initial treatment gap when the surgery took place at least 90 days after the primary surgery. Surgical procedures of mastectomy or partial mastectomy during the initial treatment were calculated to identify patients who received multiple surgeries. Multiple logistic regression models were used to identify the patient and physicianlevel predictors of multiple surgeries. Of 45,453 women with early stage breast cancer who were treated by 2,595 surgeons during the study period, 9,462 patients (20.8%) received multiple surgeries breast of these patients, 8318 (87.9% ) underwent additional surgery, 988 (10.4%) received two additional surgeries, and 156 (1.6%) received three or more additional surgeries. Between 2997 (6.6% of the entire cohort) women who underwent preoperative assessment of breast MRI, 770 received multiple breast surgeries. After adjusting the characteristics of the patient and tumor associated with multiple surgeries, he found that the rate of multiple surgeries was not significantly different between the two groups with or without preoperative breast MRI. In addition, the average odds ratio of 2.0, which corresponds to the value of the average of the relative probabilities of receiving multiple surgeries between two doctors chosen at random after controlling for other risk factors, indicated a large effect of individual surgeon. Substantial variation was observed in the rates of multiple surgeries in women 66 years or older with early stage breast cancer. The evidence does not support that preoperative breast MRI reduces the incidence of multiple surgeries.


The purpose of this study was to analyze the available evidence on the effects of breast reconstruction (BR) in the body image of women with breast cancer. BR is a potential intervention to improve body image for women with breast cancer. Contradictory research findings on the effects of breast reconstructive surgery body image compared to breast conserving surgery (BCS) or mastectomy exist. A metaanalysis of studies found in MEDLINE, CINAHL, PsychINFO, PubMed, and PQDT (thesis and dissertation), and other library resources published from 1970 to 2010 were searched. Comparable studies that examined the difference in body image among women with breast cancer who received mastectomy with PE and those with BCS were included. A clear definition of the domains of body image, including stigma body, the body concerned and transparency were identified. Effect sizes were calculated. Twelve studies were included in the metaanalysis. Women with BR and BCS were not different in the realm of body concern body image. However, women with PE had a significantly worse score in the domain of body image body stigma that women receiving BCS. Women who had a BR score better body image than women with mastectomy. Women who are dissatisfied with their body can still perceived shortcomings due to the stigma of mastectomy and affect body image. The consistent application of valid and reliable measures of body image specific to women with breast cancer is needed.


Examined in a population cohort of women, risk factors for recurrence after mastectomy for ductal carcinoma in situ pure (CDIS) and to identify which patients may benefit from radiation therapy after mastectomy. Data were analyzed for 637 subjects with pure ductal carcinoma in situ diagnosed between January 1990 and December 1999, initially was treated with mastectomy. Locoregional recurrence (LRR), the breast cancerspecific survival and overall survival were described using the KaplanMeier method. LRR reported risk factors (age, margin, size, Van Nuys prognostic index, degree of necrosis and histological subtype) were analyzed by univariate (logrank) and multivariate (Cox modeling methods). Mean followup was 12.0 years. The characteristics of the cohort were: median age 55 years, 8.6% of </ = 40 years, 30.5% of tumors> 4 cm, histological grade 3 42.5%, 37.7% and multifocal disease 4.9% positive margin. For 10 years, LRR was 1.0%, breast cancer specific survival was 98.0% and overall survival was 90.3%. All recurrences (n = 12) involved ipsilateral chest wall disease, being the most invasive disease (11 of 12). None of the 12 patients who died of breast cancer, all were successfully rescued (median of 4.4 years). Ten years LRR was higher with age </ = 40 years (7.5% vs. 1.5%, p = 0.003). Mastectomy has an excellent locoregional control of DCIS. The routine use of radiation therapy after mastectomy is not justified. The young age (</ = 40 years) LRR predicts slightly higher, but possibly due to the small number of cases with multiple risk factors for relapse, a subgroup with a high risk of LRR (ie, approximately 15% ) was not identified.


To evaluate the rate of infertility after laparoscopic ilealanal anastomosis (IPAA). Proctocolectomia total IPAA know that infertility is associated with postoperative open surgery, which can be caused by pelvic adhesions that affect the fallopian tubes. However, fertility after laparoscopic IPAA has not been evaluated. Mall patients underwent total laparoscopic IPAA between 2000 and 2011 and were aged 45 years or less at the time of the operation, and 18 and over at the time of data collection were included . The patients answered a questionnaire by telephone fertility. All demographic and perioperative data were collected prospectively. The results were compared with those of controls undergoing laparoscopic appendectomy. Sixtythree patients were included. The average age at the time of surgery was 31 + /  9 years (range 1444). IPAA was carried out for ulcerative colitis in 73% of cases of familial adenomatous polyposis in 17%. The mean follow up was 68 after IPAA + /  33 months (range 6136). Fiftysix patients responded to the questionnaire (89%). Half of them have already had a child before IPAA. Fifteen patients attempted pregnancy after IPAA, of whom 11 (73%) were able to conceive, resulting in 10 ongoing pregnancies and 1 miscarriage. The overall fertility rate was 27%. There were no differences in fertility over time compared with 14 controls who attempted pregnancy during the same period (90% versus 86% at 36 months, P = 0.397). The infertility rate seems lower after laparoscopic IPAA than after open surgery.


Communication between the surgeon, pathologist and oncologist in radiation enhancement using a virtual model of the definitive resection combining 3D images with computer assisted navigation. Locates the pathologist and oncologist margins questionable plans focused delivery of radiation to native tissue in an area of ​​complex anatomy.


The only prospective randomized trial evaluating the use of intraperitoneal drainage following pancreatic resection was published in our institution for about 10 years. This study sought to evaluate the evolution of the practice in the last 5 years. Between June 2006 and June 2011, 1,122 resections were performed. Six surgeons were divided evenly and compared with standard practice: routine drain (drains placed> 95%), selective sliding nondrainers routine (drains placed approximately 15%). Data were recorded prospectively preoperative and operative morbidity were evaluated in multivariate models and uniforms. Our surgical drainage rate was 49% and decreased over time (62% vs. 37% 20062008 20092011, P <0.001). Patients without surgical drainage with significantly less grade> / = 3 overall morbidity (26% vs 33%, p = 0.01), shorter hospital stay (7 vs 8 days, p <0.01), fewer readmissions ( 20% vs 27%, P = 0.01) and a lower rate of grade> / = 3 pancreatic fistula (16% vs. 20%, p = 0.05). Reoperació similar (both <1%), interventional radiology procedures (15% vs 19%, p = 0.1), and mortality (2% vs. 1%, p = 0.3) were observed in both groups. There was no difference between routine drain group (n = 248) and nondrainers group (n = 478) in grade> / = 3 fistula and the need for intervention radiologyguided procedures. In this study, we used operating drains about half of the time and were associated with a longer hospital stay and a grade> / = 3 disease, fistula, and readmission rates. Not only does it reduce the need for reoperation or alter mortality rates. Routine prophylactic drainage after pancreatic resection can be safely abandoned.


The aim of this pilot study was to investigate the potential longterm overall survival (OS) after liver transplantation for colorectal liver metastases (CLM). Patients with nonresectable CLM have a poor prognosis and few survive more than 5 years. LMC is now considered an absolute contraindication for liver transplantation, although liver transplantation for primary and secondary hepatic malignancies showing some excellent results in selected patients. Before 1995, the number of liver transplants for CML were made, but the result was poor (5 year survival rate: 18%) and liver transplant for CML was abandoned. Since then, the survival rate after liver transplantation in general has increased by almost 30%. Based on this, a 5year survival rate of approximately 50% after liver transplantation for CML could foresee. In a prospective pilot study, liver transplantation for nonresectable LMC was performed (n = 21). Main inclusion criteria were liver only LMC excised primary tumors and at least 6 weeks of chemotherapy. KaplanMeier estimates of the rate of SG 1, 3, and 5 years were 95%, 68% and 60%, respectively. Metastatic recurrence of the disease was common (mainly pulmonary). However, a significant proportion of the recurrences were accessible for the surgery and followup (after an average of 27 months, range 860), 33% had no evidence of disease. Tumor burden of liver disease before liver transplantation, the time of primary surgery for liver transplantation, and progressive chemotherapy were identified as significant prognostic factors. OS far surpasses the results reported by chemotherapy is the only treatment option available for this group of patients. Moreover, the operating system is comparable with resectable liver resection for CLM and survival after liver transplantation recurrence of malignant diseases. The selection strategies based on prognostic factors may further improve the results.


Latest advances on Surgery. 7-11th February 2013

Latest advances on Surgery


Intraoperative radiotherapy (RIO) allows the administration of high doses of radiation upon the lumpectomy, adjuvant radiation potentially avoid daily. A phase 2 study of Iortia pre-split was conducted for early stage breast cancer. Patients> / = 48 years of age with invasive ductal carcinoma, </ = 3 cm and clinically negative lymph nodes were eligible for this study, which was approved by the institutional review board. Ultrasound is used to select the energy of electron and size covering the tumor with more than 1.5-to 2.0 cm lateral margins and 1-cm deep margins (90% isodosi). Fifteen Gy delivered with an irradiator Mobetron and immediately followed needle localized partial masectomy. The results of local events have been updated using the Kaplan-Meier method. A total of 53 patients received Iortia alone. The median age was 63 years and median tumor size was 1.2 cm. Of these, 81% were positive for estrogen receptors and progesterone receptors, 11% were positive for the receptor of human epidermal growth factor 2, and 15% were triple negative. In addition, 42%, 49% and 9% have fallen into appropriate groups, and inadequate precautionary, respectively, of the American Society of Therapeutic Radiation Oncology consensus statement for accelerated partial breast irradiation. Mean follow-up was 69 months. Ipsilateral events occurred in 8 of 53 patients. The current rate of ipsilateral events 6 years was 15% (95% confidence interval = 7% -29%). The crude event rate for appropriate groups and Cautionary was 1 of 22 (5%) and 7 of 26 (27%), respectively. The survival rate was 94.4%, and breast cancer-specific survival was 100%. The rate of local events in this study is a concern, especially in the group with morality. Based on these findings, pre-split Iortia as delivered in this study may not provide adequate control of breast less favorable early stage. Cancer 2013;. (C) 2013 American Cancer Society.


Lung cancer patients with chronic obstructive pulmonary disease have an increased risk of cardiovascular and respiratory complications after lung resection. The aim of this study was to evaluate the clinical effects of low-dose human atrial natriuretic peptide (hANP) on postoperative cardiopulmonary complications in patients without chronic obstructive pulmonary disease undergoing surgery for lung cancer. Of 824 patients who underwent a procedure of choice pulmonary resection for lung cancer in two specialized thoracic centers between 2008 and 2011, 202 consecutive patients who had airflow limitation before surgery were included in this study retrospective. The results were compared between patients receiving and not receiving hANP during the perioperative period. The primary end point was the incidence of postoperative cardiopulmonary complications. Hemodynamic postoperative white blood cell counts (WBC) and C-CRP levels (CRP) were also examined. In addition, propensity score analysis was used to reduce selection bias in treatment of patient characteristics. RESULTS: The incidence of postoperative cardiopulmonary complications was significantly lower in the hANP group than in the control group (14 vs 36%, P <0.01). Propensity score analysis confirmed the significantly lower frequency of postoperative cardiopulmonary complications in the hANP group. Patients in the hANP group showed significantly lower leukocyte counts and serum levels of CRP after surgery. HANP treatment during the perioperative period had a prophylactic effect against postoperative cardiopulmonary complications in patients with chronic obstructive pulmonary disease undergoing surgery for lung cancer.


A new diagnosis of COPD is often made during the assessment of patients requiring surgery for lung cancer. The aim of this study was to evaluate the clinical effects of inhaled tiotropi on postoperative cardiopulmonary complications in untreated patients with chronic obstructive pulmonary disease requiring surgery for lung cancer. A retrospective study that included 104 consecutive patients with chronic moderate to severe COPD who underwent a lobectomy for lung cancer in two specialized thoracic centers between April 2008 and October 2011 was performed. The results were compared between patients receiving and not receiving inhaled tiotropi during the perioperative period. The primary end point was the incidence of postoperative cardiopulmonary complications. Postoperative white blood cells and C-reactive protein as biomarkers of inflammation were also examined. The incidence of postoperative cardiopulmonary complications was significantly lower in the group that tiotropi in the control group (18% vs 48, p = 0.001). Patients tiotropi group also showed significantly lower blood counts, white cell count and C-reactive protein levels after the operation. Tiotropi inhaled therapy during the perioperative period had a prophylactic effect on postoperative cardiopulmonary complications in patients with newly diagnosed chronic obstructive pulmonary disease requiring surgery for lung cancer.


Patients with metastatic gastric cancer have a poor survival. The purpose of this study was to compare the outcomes of patients with metastatic gastric cancer stratified by surgery and radiotherapy. Results Surveillance, Epidemiology and late (SEER) database access to identify cancer patients with AJCC stage IV gastric M1 (based on the American Joint Committee on Cancer Staging Instructions, 6 edition) from 2004 to 2008 . The patients were divided into 4 groups: group 1, no surgery or radiation, group 2, the radiation alone group 3, the surgery alone group 4, surgery and radiation. Survival analysis was determined by the Kaplan-Meier and log-rank analysis. Multivariate analysis (MVA) model was analyzed by Cox proportional hazard ratio. A total of 5072 patients were identified. Surgery and / or radiotherapy is associated with a survival benefit. The median survival and 2 years for groups 1, 2, 3 and 4 was 8.2% and 7 months, 8 months and 8.9%, 18.2% and 10 months, and months 16 and 31.7%, respectively (p <0.00001). MVA for all patients revealed that surgery and radiotherapy were associated with reduced mortality, whereas T-stage, N-stage, age, histology seal ring and peritoneal metastases were associated with mortality. In patients treated with surgery, radiation demonstrated that MVA was associated with reduced mortality, whereas T-stage, N-stage, age, removal of <15 lymph nodes, histology ring seal and peritoneal metastasis was associated with increased mortality. Age was the only prognostic factor in patients who did not undergo surgery. Surgery and radiation is associated with increased survival in a subset of patients with metastatic gastric cancer. Prospective trials will be necessary to address the role and sequence of surgery and radiotherapy for metastatic gastric cancer.


To test whether or not the association between inflammation and pancreatic ductal adenocarcinoma (PC) is provided by the susceptibility of the host, specifically by genetic polymorphisms in genes related to inflammation. Inflammation has been linked PC. The reports cited an increased expression of proinflammatory mediators such as NF-kappaB and COX, but not in PC-adjacent normal tissue, suggesting a possible role in carcinogenesis. We tried to understand the role that genetic variants in the inflammatory pathway NF-kappaB play in the development and progression of PC. We genotype 1536 tag single nucleotide polymorphisms (SNPs) in 102 candidate genes of multiple inflammatory pathways in 1308 white patients with CP were divided into 3 groups according to the extent of the disease: healing resection (n = 400), locally advanced / resected (n = 443) and metastatic (n = 465). Survival analysis was performed using Kaplan-Meier and Cox proportional regression hazard. The statistical significance was set at less than 0.001 for the control of multiple testing. The average age was 67 (28.0 to 91.0) years, and 57% were men. Median survival for each of the 3 groups (resected, locally advanced and metastatic) was 23.7, 9.4, and 6.6 months, respectively (P <0.0001). In the resection group, carriers of the minor allele for either rs3824872 (MAPK8IP1) and rs8064821 (SOCS3) were associated with 10 – and 6-month survival advantage compared with non-carriers in patients with resected, with an additional two years of survival if both minor alleles were present. In locally advanced disease, SNP rs1124736 (IGF1R) was associated with better survival if they had a copy of the G allele, the risk ratio of 0.57 (95% CI: 0.42 to 0.77 ), p = 0.0002. In addition, 4 SNPs in patients with metastatic disease is associated with a worse survival and 2 associated with better overall survival, but differences in survival were not considered clinically significant. SNPs in inflammatory genes via MAPK8IP1 and SOCS3 is associated with increased overall survival in patients undergoing potentially curative resection and in the future can be used as markers to predict survival. Future research is needed to determine the functional relevance of these loci.


To examine the relationship between weight in early adulthood and middle adult weight gain and the risk of knee and hip osteoarthritis. In the initial interview during 1990-94, 38,149 participants [mean age 54.9 years (SD 8.6)] of the Study Cohort Collaboration Melbourne were asked to recall their weight at the age of 18-21 years and had their height measured average age and weight. Total knee and hip osteoarthritis between 2001 and 2009 was determined by linking the cohort records for Registry.Results Australian Orthopaedic Association National Joint Replacement. More weight and BMI in the 18-21 years and the average age, weight gain and overweight persistent during this time were associated with an increased risk of total knee and hip. Middle Age Weight [hazard ratio (HR) per 5 kg 1.25 (95% CI: 1.23, 1.27) for knee vs. 1.11 (1.09, 1.14) for the hip] il’IMC [HR per 5 kg / m (2) 1.80 (1.72, 1.89) versus 1.29 (1.21, 1.37)] and adult weight gain [HR for 5 kg each 1.25 (1.23, 1.28) vs 1.10 (1.07, 1.13)] were more strongly associated with the risk of total knee replacement total hip replacement (p for the heterogeneity of HR <0.0001). Higher body weight and BMI in early adulthood and middle weight gain and overweight persistent since the early middle adulthood, risk factors for knee and hip OA. Weight gain in adults confers increased risk of hip OA knee OA. Weight control in early adulthood and avoiding weight gain are important for the prevention of osteoarthritis.


To determine whether patients with 1, 2 or 3 positive lymph nodes (LN) have similar survival outcomes. We analyzed the Surveillance, Epidemiology and End Results registry of patients with breast cancer diagnosed between 1990 and 2003. We identified 10,415 women with T1-2N1M0 breast cancer who were treated with mastectomy without adjuvant radiation, with at least 10 LN examined and at 6 months. The Kaplan-Meier and log-rank test was used for survival analysis. Multivariate analysis was performed using the Cox proportional hazards model. Mean follow-up was 92 months. Ten-year overall survival (OS) and cause-specific survival (CSS) were worsened progressively increase the number of positive LN. Survival rates were 70%, 64%, and% 60 (OS), and 82%, 76% and 72% (CSS) for 1, 2, and 3 LNS positive, respectively. Pairwise log-rank test P values ​​were <.001 (1 vs 2 positive LNS) <.001 (1 vs 3 positive LNS), and 0002 (3 vs 2 LNS positive). Multivariate analysis showed that the number of positive LN was a significant predictor of OS and CSS. The risk ratios increased with the number of positive LNS. In addition, age, primary tumor size, grade, estrogen receptor status and progesterone receptors, race and year of diagnosis were significant prognostic factors. Our study suggests that patients with 1, 2, and 3 have different results LNS positive survival by increasing the number of positive LN associated with poorer OS and CSS. The grouping conventional LNS positive 1-3 should be reconsidered.


The Lymphedema is a dreaded complication of surgery for breast cancer. We assessed trends in the development of lymphedema, patient concerns, and behavioral risk reduction. Prospectively recorded 120 women undergoing sentinel node biopsy (SNB) or axillary lymph dissection (DGLA) for breast and upper extremity lymphedema volume assessed before surgery and at 6 and 12 months after surgery . We defined as a change of lymphedema volume> 10% of baseline in terms of contralateral upper extremity. The patients completed a validated instrument assessing lymphoedema concern and to reduce the risk behaviors. Associations were determined using Fisher’s exact test range and personal signature. After 6 months, lymphoedema was similar between patients with SLNB and DGLA (p = 0.22) but was higher in women DGLA 12 months (19% vs 3%, p = 0.005). A clear relationship between the relative change in limb volume over 6 and 12 months (Kendall tau coefficient 0.504, p <0.001). Among women with 0 to 9 Change in volume% at 6 months, 22% had progressive swelling, and 18% resolved their volume changes at 12 months. Overall, 75% of DGLA and 50% of patients with sentinel node was ongoing concern about lymphedema in monitoring, and there was no difference in the number of reducing risk behaviors practiced between the 2 groups (p> 0, 34). Volumes of the upper fluctuate and there is a latent period before the development of lymphedema. Despite the low risk of lymphedema after SLNB, most women are concerned about lymphedema and reduce risk behavior practice. Additional studies in the first volume changes in the upper limb is justified to allay the fears of the majority of women and better predict which women will lymphoedema.

Latest advances on surgery. 1-6 February 2013

Latest advances on surgery.


Zonulin is a recently discovered protein that plays an important role in the regulation of intestinal permeability. Their previous study showed that probiotics may decrease the rate of infectious complications in patients undergoing elective surgery for colorectal cancer. The objective was to determine the effects of perioperative administration of probiotics on serum concentrations zonulina and subsequent effect on postoperative infectious complications in patients undergoing colorectal surgery. A total of 150 patients with colorectal carcinoma were randomly assigned to the control group (n = 75) who received placebo or the probiotic group (n = 75). Both probiotics and placebo administered orally for 6 days before surgery and 10 d after the operation. The results were measured by assessing bacterial translocation, intestinal permeability postoperative serum concentrations zonulina, duration of postoperative fever, and the cumulative duration of antibiotic therapy. The rate of postoperative infection, the positive rate of microbial DNA in the blood and the incidence of postoperative complications, including infectious infection sepsis, central line infections, pneumonia, urinary tract infection and diarrhea were also assessed. The infection rate was lower in the probiotic group than in the control group (P <0.05). Probiotics reduce zonulina serum concentration (P <0.001), duration of postoperative pyrexia, the duration of antibiotic therapy, and the rate of postoperative infectious complications (all P <0.05). The p38 mitogen-activated kinase signaling pathway protein was inhibited by probiotics. Probiotic treatment can reduce the rate of perioperative and postoperative sepsis is associated with lower serum concentrations zonulina in patients undergoing colectomy. They propose a regulatory model that could explain this clinical association.


Bradykinin increases during extracorporeal circulation (ECC) and stimulates the release of nitric oxide, inflammatory cytokines and tissue-type plasminogen activator (t-PA) through B (2) receptor. This study tested the hypothesis that endogenous bradykinin contributes to the inflammatory and fibrinolytic CEC and the bradykinin B (2) receptor antagonism reduces fibrinolysis, inflammation, and subsequent transfusion requirements. Patients (N = 115) were prospectively randomized to placebo, epsilon-aminocaproic acid (EACA) or HOE 140, a bradykinin B (2) receptor antagonist. The bradykinin B (2) receptor antagonism reduces intraoperative fibrinolytic capacity as much as EACA, but only EACA decreased D-dimer formation and tended to decrease postoperative bleeding. Although EACA and HOE 140 decreased fibrinolysis and blood loss tempered EACA, these treatments did not reduce the proportion of patients transfused. These data suggest that endogenous bradykinin contributes to the generation of t-PA in patients undergoing CPB, but the additional effects on the generation of plasmin contribute to the reduction of D-dimer concentrations during EACA treatment.


Conducted a meta-analysis to assess the effectiveness and safety of laparoscopic-assisted gastrectomy (LAG) versus open gastrectomy for resectable gastric cancer. We searched EMBASE, Cochrane Library, PubMed, Science Citation Index (SCI) database Chinese biomedical literature to identify randomized controlled trials (RCTs) that since its inception in April 2012. The meta-analysis was performed using RevMan 5.0. This is consistent with the elements of information preferred by systematic reviews and meta-analysis states. The quality of evidence was evaluated by GRADEpro 3.6. Eight RCTs with a total of 784 patients were analyzed. Compared with open gastrectomy group, there were no significant differences in postoperative mortality (OR = 1.49, 95% CI 0.29 to 7.79), dehiscence of the anastomosis (OR = 1.02, 95% CI 00:24 to 4:27), in general the average harvested lymph nodes [weighted mean difference (WMD) = -3.17, 95% CI -6.39 to 0.05], overall morbidity of postoperative complications (OR = 0.54, 95% CI 0.36 to 0.82), estimated blood loss (MD = -107.23, 95% – 148.56 to -65.89), frequency of administration analgesics (MD = -1.69, 95% CI -2.18 to -1.21, p <0.00001), the incidence of pulmonary complications (OR = 0.43, 95% CI 0.20 – 0.93, p = 0.03) was significantly lower in GAL, LAG had less time to start the first flat (MD = -0.23, 95% CI: -0.41 to -0, 05) and decreased hospital stay (MD = -1.72, 95% CI -3.40 to 0.04), but still had more LAG operating time (MD = 76.70, 95% CI 51.54 to 101.87). On the basis of this meta-analysis concludes that although LAG was still a time-consuming procedure and technically dependent, has the advantage of better results in the short term. Long-term survival data from other studies are urgently needed to estimate the survival benefit of this technique.


The effectiveness of local anesthetic wound infiltration for the treatment of acute and chronic postoperative pain is controversial and there are no detailed studies. The primary objective of this study was to evaluate the influence of ropivacaine wound infiltration on chronic pain after breast surgery. In this prospective, randomized, double-blind, parallel group, placebo-controlled study, 236 patients undergoing surgery for breast cancer were randomized (1:1) to receive either placebo or ropivacaine infiltration of the wound, the second and third intercostal space and the humeral insertion of the pectoralis major. Acute pain, analgesic consumption, nausea and vomiting were assessed every 30 minutes for 2 hours in the Resuscitation Unit and every 6 h for 48 h. Chronic pain was assessed 3 months, 6 months and 1 year after surgery by the Brief Pain Inventory, hospital anxiety and depression, and neuropathic pain questionnaires. Ropivacaine wound infiltration significantly decreased postoperative pain for the first 90 minutes, but did not reduce chronic pain at 3 months (primary endpoint), and at 6 and 12 months after the operation. At 3 months, the incidence of chronic pain was 33% and 27% (P = 0.37) in group ropivacaine and placebo, respectively. During follow-up, brief pain inventory, neuropathic pain and anxiety increased with time in both groups (p <0.001), whereas depression was stable. There were no complications. This multicenter, prospective study indicates that wound infiltration of ropivacaine after breast cancer surgery reduces postoperative pain, but did not reduce chronic pain at 3, 6 and 12 months after surgery.


Olaparib (AZD2281) is an inhibitor of poly (ADP-ribose) polymerase (PARP) inhibitor with antitumor activity in cancer patients with BRCA1 / 2 germline mutations in patients with deficient homologous recombination. In this research study dose, patients were randomly assigned to olaparib 10, 30, 100, 200 or 400 mg (capsule formulation) twice daily for 4-5 days prior to surgery cancer breast. The main objective was to identify the biological effective dose of olaparib for future trials. Secondary objectives included the evaluation of the dose of PARP-1 inhibition / exposure-response and safety. Olaparib plasma pharmacokinetics (PK) and pharmacodynamics (PD) in the tumor cells and peripheral blood mononuclear cells (PBMCs) were evaluated. Population PK / PD modeling was performed on pooled data from this study and a study previously reported. Sixty patients were randomly assigned (n = 12 each dose). Dose-dependent increase exposure to olaparib were observed, but ~ 50% lower plasma levels of exposure observed in advanced studies of the disease. The average maximum extent of inhibition of PARP in PBMC and tumor tissue was 50.6% and 70.0%, respectively, and were similar to levels previously reported inhibitors. No PARP inhibition dose relationship was observed. Due to olaparib exposure unexpectedly low, we could not determine a biological effective dose. Common side effects include pain procedure (n = 31 patients), nausea, fatigue, malaise and increased blood creatinine (n = 6 each), which were mild to moderate intensity, and all were manageable. Although exposure under olaparib, PARP inhibition was consistent with previous reports. The reasons for the differences between studies in the exhibition are unclear. The tolerability profile of olaparib was consistent with previous studies.


The influence of hospital and surgeon volume on survival after surgery of esophageal cancer deserves clarification, particularly the prognosis after early postoperative period. The interaction between hospital and surgeon volume, and the influence of known prognostic factors need to be taken into account. A nationwide Swedish population-based cohort study of 1,335 patients with esophageal cancer underwent esophageal resection in 1987 and 2005, with follow-up for survival until February 2011, was carried out. The associations between annual hospital volume, surgeon annual volume, surgeon volume and cumulative mortality risk were calculated using a parametric multivariate analysis of survival, providing hazard ratios (HR) with 95%. CRI were mutually adjusted for variables of volume of surgery and subsequently adjusted for prognostic factors age, sex, comorbidity, calendar period, tumor stage, tumor histology, and adjuvant therapy. There were no independent association between hospital volume and annual overall survival and hospital volume was not associated with short-term mortality after adjustment for the effect of clustering hospital. A combination of higher volume surgeon reduced the annual and cumulative mortality occurs at least 3 months after surgery (P trend <0.01), the HR was 0.78 (95% CI, 0.65 – 0.92) compared with volume surgeons both annual and cumulative average over those below the median. These results were maintained when the group surgeon and hospital were taken into account. As the volume surgeon rather than hospital volume independently influence prognosis after surgery of esophageal cancer, the centralization of such surgery unless surgeons seem to be guaranteed.


The choice of fundoplication for the surgical treatment of gastroesophageal reflux disease (GERD) is still debated. Monitoring multichannel intraluminal impedance (MII) has not been used for comparing the objective data and subjective comparative data on laparoscopic Nissen and Toupet fundoplication are scarce. This study randomized 125 patients with documented chronic GERD fundoplicatura any laparoscopic floppy Nissen (LNF, n = 62) or laparoscopic fundoplication fundoplicatura (LTF, n = 63). The Gastrointestinal Quality of Life Index (GIQLI), the classification of symptoms, esophageal manometry and MII data were documented before surgery and 1 year after surgery. The data before and after the procedure were compared. The statistical significance was set at a P value less than 0.01. Both procedures resulted in significantly GIQLI and symptoms of GERD. Preoperative dysphagia improved in both groups, but the improvement reached significance only in the LTF group. The ability to rotate proved to be significantly decreased after LNF than after LTF. Gas and bloating and symptoms of “atypical” extraesofágicas also significantly decreased after surgery (p <0.01). However, the intestinal symptoms were almost the same in both groups. Both procedures resulted in a significant improvement of the lower esophageal sphincter pressure. The improvement was greater in the LNF group in the LTF group (p <0.01). DeMeester score and the number of total acid proximal right recumbent reflux episodes decreased in both groups after surgery (p <0.01). No significant difference between the procedures in terms of data IBD was found. Six patients (4.8%) had to undergo intra reoperació to slip the envelope. All patients had undergone LNF. Both procedures proved to be equally effective in improving the quality of life and symptoms of GERD. However, dysphagia and reoperation rates were lower and the ability to rotate after LTF was higher after LNF.


Randomized controlled trials (RCTs) have demonstrated equivalent survival to conserve if radiation therapy (BCT) and mastectomy for early stage breast cancer. A large population-based series of women who underwent mastectomy or BCT was studied to see if the results of RCTs were conducted in the general population, and if survival differ according to the type of surgery when stratified by age and hormone receptor (HR) status. We obtained information on all women diagnosed in the state of California stage I or II breast cancer between 1990 and 2004 who were treated with mastectomy or BCT and followed for vital status and December 2009. Cox proportional hazards modeling was used to compare overall survival (OS) and disease-specific survival (DSS) between BCT and mastectomy groups. The analysis was stratified by age (<50 years and> / = 50 years) and tumor HR status. A total of 112,154 women met the eligibility criteria. Women undergoing BCT had improved OS and DSS compared with women with mastectomy (adjusted hazard ratio for the entire U.S. cohort = 0.81, 95% confidence interval [CI] = 0.80 to 0.83) . The benefit DSS with BCT compared to mastectomy was higher among women> / = 50 with HR-positive disease (hazard ratio = 0.86, 95% CI = 0.82 to 0.91) than women <50 with HR-negative disease (hazard ratio = 0.88, 95% CI = 0.79 to 0.98), but this trend was observed among all subgroups analyzed. Among patients with early stage breast cancer, BCT was associated with improved DSS. These data provide confidence that BCT remains an effective alternative to mastectomy for early stage disease, regardless of age or state of human resources.


Latest advances on Surgery: 10-20 Jan 2013

Latest advances on Surgery.

Respiratory failure of acute lung injury (ALI), acute respiratory distress syndrome (ARDS) and pneumonia are the leading causes of morbidity and mortality after esophagectomy for esophageal cancer. This study was conducted to investigate whether intraoperative corticosteroids can attenuate postoperative respiratory failure. Between November 2005 and December 2008, 234 consecutive patients undergoing esophagectomy for esophageal cancer were reviewed. A 125-mg dose of methylprednisolone was administered after performing the anastomosis. ALI, ARDS and pneumonia occurring before postoperative day (POD) 7 were considered as acute respiratory failure. The average age was 64.2 ± 8.7 years. One hundred fifty-one patients were in the control group and 83 patients in the steroid group. Patient characteristics were comparable. The incidence of acute respiratory failure was lower in the steroid group (P = 0.037). The incidence of anastomotic leakage and wound dehiscence was not different (P = 0.57 and P = 1.0). The level of C-reactive protein on POD 2 was lower in the steroid group (P <0.005). Multivariate analysis indicates that intraoperative steroid was a protective factor against acute respiratory failure (p = 0.046, OR = 0.206). Intraoperative administration of corticosteroids was associated with a lower risk of acute respiratory failure after esophagectomy. Laboratory data suggest that corticosteroids may attenuate the inflammatory responses induced by the stress of surgery.

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Bilateral autogenous breast tissue reconstruction often requires microsurgical tissue transfer. The reality is that sometimes revascularization can not be achieved, leading to a total failure of the flap. If a flap survives another attempt using a second flap is necessary to achieve symmetry. Nonmicrosurgical options to achieve this are limited. If the flap is bulky enough success can be divided into two to create a local island pendant based on original pedicle flap to allow the termination of the contralateral reconstruction. This concept is presented here with a fraction of the deep inferior epigastric artery perforator flap breast reconstruction bilateral sequential.

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The development of surgery in low and middle income countries has been limited by the belief that it is too expensive to be sustainable. However, surgical subspecialist care may provide important clinical and economic benefits in low-resource environments. The aim of this study was to describe the clinical and economic impact of recurring trips short term plastic surgery in low and middle income countries. The authors retrospectively reviewed the clinical and operational Blocks hands through the surgical experience of the World Equator. The authors calculate disability-adjusted life years averted estimate the clinical impact of repairing cleft and calculated the economic impact of surgery for the disease once. One thousand one hundred and forty two cases of reconstructive surgery were performed over 15 years. The surgery is performed most often by scar contractures [449 cases (39.3 percent)], which burns scars included a substantial amount [215 cases (18.8 percent)]. There were 40 postoperative complications within 7 days after the operation (3.5 percent), and partial wound dehiscence was the most common complication [16 of 40 (40 percent)]. Both disorders constituted 277 cases (24.3 percent) and 102 cases were primary cleft lip and / or palate cases. Between 396 and 1042 total disability-adjusted life years were prevented by these 102 cases surgery to repair cleft primary. This translates into a profit of between $ 4.7 billion (human capital approach) and U.S. $ 27.5 million (the value of a statistical life approach). Disease plastic surgery is a significant source of morbidity for patients in regions with limited resources. Dedicated programs that provide essential reconstructive surgery can produce significant clinical and economic benefits to the host countries.

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Prompted by reports of decreased donor site morbidity, deep inferior epigastric (DIEP perforator) flaps have gained significant popularity. Increasing body mass index is associated with poor outcomes in breast reconstruction using traditional techniques. The authors objective is to define the rate of complications with increasing body mass among patients undergoing DIEP flap breast reconstruction. A retrospective analysis of 639 DIEP flap was performed in 418 patients. Patients were stratified into five groups according to BMI. The data on medical comorbidities, adjunctive therapies, timing of reconstruction, active smoking and surgical history were collected. Primary outcomes were compared between groups. The average BMI for the entire population was 28.3 (range, 17 to 42). Rate of increase in body mass was associated with a higher incidence of hypertension prior to abdominal surgery, and duration of follow-up. Stratified by complications with the pendant group showed a significant delay in wound healing complications in severely obese patients compared with groups of children body mass index. Donor complications stratified by BMI showed slow healing of the wound and significantly increased overall complications in patients with morbid obesity compared to other groups. Effect of the formation of abdominal wall hernia bulging was not significantly different between groups. Increasing BMI predisposes patients to delayed wound healing complications, both flap donor sites and locations. However, overall flap complications being similar in all BMI groups. Stability of the abdominal wall remains. Given a profile similar flap complications and maintaining stability abdominal DIEP flaps are recommended in patients with a higher body mass index.

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The authors aimed to differentiate between combined / integrated and independent (traditional) methods of training in plastic surgery in terms of quality of students, the caliber of graduates and the results of practice or career after graduation. To compare combined / integrated with an independent training residency program, the authors conducted a study based on the website of the American Society of Plastic Surgeons members seeking their experiences and results of practice (n = 1056) and interviews Teachers plastic surgery that looks quality students (n = 72). The survey assessed member background, credentials research, satisfaction path poster activities, current practice and academic affiliation. Interviews focused on the faculty of teachers knowledge base, judgment diagnosis and treatment, technical skills, research skills and prediction of future professional success. The survey of members showed no difference (p> 0.05) between students combined / integrated and independent of the type of practice (cosmetic / reconstructive), volume practice or academic achievement. Combined / Integrated trained surgeons are three times more likely to recommend their training program and twice as likely to enter into fellowship after residency. Alpha Omega Alpha Medical Honor Society member correlated with a higher probability of having an academic practice at 5 and 10 years or more and increased teacher qualifications. Faculty evaluations showed that residents combined / integrated knowledge were higher (49 percent versus 32 percent), but the residents were independent higher technical skills (51 percent versus 20 percent) and research ( 57 percent versus 19 percent). Most teachers were not able to choose one way over producing residents. With regard to future results of the practice, there was no way in higher education. About the quality of the students were no differences in the evaluations of the faculty, but there was no consensus on a better path.

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Angiography by computed tomography is widely used for obtaining information on the donor abdominal vascular site for microsurgical breast reconstruction. The purpose of this paper is to present the experience of the author with computed tomography angiography for preoperative donor and recipient sites for a series of microsurgical breast reconstruction procedures. A total of 71 patients preparing for autologous breast reconstruction with deep inferior epigastric artery (DIEP perforator) flaps undergo preoperative angiography with computed tomography fields explored, from the collarbone to the symphysis pubis. Preoperative evaluation included computed tomography based on the anatomy of the intercostal space, the internal mammary artery and vein and internal mammary artery to determine which drill intercostal space would be addressed. The breast volume and the volume of the fin were calculated using abdominal computed tomography volumetry from. In 67 patients, the internal mammary vessel was quickly exposed intercostal space before the operation designated by the technique of nerve preservation. The design of the fins, including vascular pedicles was performed with the help of the relationship from volumetric computed tomography (mean, 0.64) between the core and abdominal fins patients. The volumetric ratio ultimately correlated with the ratio of the weight of the flap insertion real flap harvested weight (mean, 0.63). Computed tomography angiography for preoperative donor and recipient site provides valuable information for the planning and execution of microsurgical breast reconstruction. Computed tomography based on anatomy and volumetric approach to facilitate the harvest of receivers and glasses free DIEP flaps.


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The Centers for Medicare & Medicaid Services has a list of 10 conditions acquired in hospitals because hospitals and doctors are reimbursed, as it believes that these conditions are preventable and should be considered “never events.” To assess the validity of this premise, the authors performed an analysis of the real-life incident and categories of events that never occur in a cohort of breast reconstruction plastic surgery practice multisurgeon. Analysis of the estimated cost of the factors of loss of income and risk associated with the development of events never listed. A retrospective review of medical records of patients undergoing mastectomy undergo breast reconstruction from 2008 to August 2010 was performed. A total of 297 patients were identified and International Classification of Diseases, Ninth Revision codes corresponding to the events of interest were never applied to the study population. Of the 297 patients, 24 (8.08 percent) never develop events into two categories: surgical site infection (7.74 percent) and catheter related urinary tract infections (0.34 percent). There were no complications in the remaining eight categories. BMI overweight and diabetes were strong independent risk factors for the development of events ever (p <0.0001). Cost estimates of lost revenue and associated economic analysis reveals considerable financial burdens for doctors and hospitals as a result of nonreimbursement. The “one size fits all” of the Centers for Medicare and Medicaid Services may be misplaced and misleading. Some risk factors are independent predictors of the development of an event ever, making it impossible to classify certain results as “never” occurrences. The pendulum never events may have swung dramatically to the left, and the time necessary to reach equilibrium.

Major Advances in Surgery: Bilateral Internal Mammary Artery Grafting Enhances Survival in Diabetic Patients: A 30-Year Follow-Up of Propensity Score-Matched Cohorts.

Major Advances in Surgery: The following article has been published recently in one of the best surgical journals.

Source: Circulation

Authors: Paul A. Kurlansky,et al

Affiliation: Florida Heart Research Institute, 4770 Biscayne Boulevard, Suite 500, Miami, FL 33137

Original title: Bilateral Internal Mammary Artery Grafting Enhances Survival in Diabetic Patients: A 30-Year Follow-Up of Propensity Score-Matched Cohorts.



BACKGROUND: The prevalence of diabetes is increasing at an unprecedented rate, affecting nearly 8% of the population. Previous studies have demonstrated a potential benefit for surgical over interventional revascularization in this group of patients. Similarly, studies have shown the superiority of bilateral internal mammary artery grafting (BIMA) over single internal mammary artery grafting (SIMA) in select populations. However, concerns regarding sternal wound infection (SWI) have discouraged the use of BIMA grafting in diabetics. Therefore, we studied the long-term results of BIMA vs. SIMA grafting in a large population of diabetic patients in which BIMA grafting was broadly applied.


METHODOLOGY: Between February 1972 and May 1994, 1107 consecutive diabetic patients underwent coronary artery bypass grafting (CABG) with either SIMA (n=646) or BIMA (n=461) grafting. Optimal matching using propensity score-matching was used to create matched SIMA (n=414) and BIMA (n=414) cohorts. Cross-sectional follow-up (6 weeks to 30.1 years, mean 8.9 years) determined long-term survival.


FINDINGS: There was no difference in operative mortality (OM) sternal wound infection (SWI) or total complications between matched SIMA and BIMA groups (OM: 10/414; 2.4% vs. 13/414: 3.1%, P=0.279; SWI 7/414; 1.7% vs. 13/414; 3.1%; P=0.179); total complications 71/414, 17.1% vs. 71/414, 17.1%, P=1.000). Late survival was significantly enhanced with the use of BIMA grafting (median survival SIMA 9.8 years vs. BIMA 13.1 years; P=0.001). Use of BIMA was found to be associated with late survival on Cox regression (P=0.003).


MAIN OUTCOME and COMMENTS by Top Surgery: BIMA, compared with SIMA, grafting in propensity score-matched patients provides diabetics with enhanced survival without any increase in perioperative morbidity or mortality.

Major Advances in Surgery: Survival prognostic factors in patients with glioblastoma.

Major Advances in Surgery: The following article has been published recently in one of the best surgical journals.

Source: J Neurosurg Sci

Authors: RJ Galzio  et al

Afilliation: Department of Health Sciences, University of L’Aquila, L’Aquila, Italy.

Original title: Survival prognostic factors in patients with glioblastoma: our experience.



BACKGROUND: Approximate survival for glioblastoma is less than 1 year. Age, histological features and performance status at presentation represent the three statistically independent factors affecting longevity. The purpose of the study was to assess the role of surgery and to analyze prognostic factors in our patients operated for glioblastoma.

METHODOLOGY: We evaluated in 56 patients who had surgery for their glioblastoma multiforme. Their depressive and performance status in the preoperative and postoperative time. Moreover we analyzed the extent of surgery, the site and the size of lesions.

FINDINGS: Median overall survival was 17 months. An age of ≥60 years (P<0.03), a preoperative Karnofsky Performance Status KPS≤70 (P=0.04), a subtotal tumor resection (P<0.001), a tumor size >5 cm (P=0.01), and no postoperative adjuvant treatment (P=0.01) were associated with the worst prognosis. Before surgery we found the presence of depression in 10 patients with a significative reduction of mean Back Depression Inventory scores after tumor resection (P=0.03). Finally, a KPS≤70 was significantly associated with an increased incidence of depression in the postoperative time.

CONCLUSIONS: Tumor size, total resection and affective disorders were identified as predictors of survival in our series of patients with glioblastoma in addition to age and KPS score. In our opinion an early diagnosis and the use of specific safeguards in the operating room contribute to have an extension of the tumor progression time and median survival.

COMMENTS by Top Surgery: Other than organic parameters we cannot forget the emotional status of these patients. Depression is too common and it does not help the patient in any way. In our opinion it is imperative that we tackle these issues. Quality of life in these patients should be addressed as much as possible as they have a very steep way ahead of them.

Major Advances In Surgery: Surgical Stress Promotes The Development Of Cancer Metastases.

Major Advances in Surgery: The following article has been published recently in the best best surgical journal.

Source: Ann Surg

Authors: Auer RA et al

Afilliation: Department of Surgery, Division of General Surgery, University of Ottawa, Ottawa, Canada; Center for Innovative Cancer Research, Ottawa Hospital Research Institute, Ottawa, Canada and Department of Medicine, Ottawa Hospital, Ottawa, Canada.

Original title: Surgical Stress Promotes the Development of Cancer Metastases by a Coagulation-Dependent Mechanism Involving Natural Killer Cells in a Murine Model.



OBJECTIVES: To determine whether the postoperative hypercoagulable state is responsible for the increase in metastases observed after surgery.

BACKGROUND: Surgery precipitates a hypercoagulable state and increases the formation of cancer metastases in animal models. Coagulation promotes metastases by facilitating the formation of microthrombi around tumor cell emboli (TCE), thereby inhibiting natural killer (NK) cell-mediated destruction.

METHODOLOGY: Mice underwent surgery preceded by tumor cell inoculation to establish pulmonary metastases in the presence or absence of various perioperative anticoagulants. Pulmonary TCE were quantified and characterized using fluorescently labeled fibrinogen and platelets. The role of NK cells was evaluated by repeating these experiments after antibody depletion in a genetically deficient strain and by adoptively transferring NK cells into NK-deficient mice.

FINDINGS: Surgery resulted in a consistent and significant increase in metastases while a number of different anticoagulants and platelet depletion attenuated this effect. Impaired clearance of TCE from the lungs associated with an increase in peritumoral fibrin and platelet clot formation was observed in surgically stressed mice, but not in control mice or mice that received perioperative anticoagulation. The increase in TCE survival conferred by surgery and inhibited by perioperative anticoagulation was eliminated by the immunological or genetic depletion of NK cells. Adoptive transfer experiment confirms that surgery impairs NK cell function.

CONCLUSIONS: Surgery promotes the formation of fibrin and platelet clots around TCE, thereby impairing NK cell-mediated tumor cell clearance, whereas perioperative anticoagulation attenuates this effect. Therapeutic interventions aimed at reducing peritumoral clot formation and enhancing NK cell function in the perioperative period will have important clinical implications in attenuating metastatic disease after cancer surgery.

COMMENTS by Top Surgery: Taking into account the advances that this scientific article shows it would be a great idea to do a clinical assay in humans.

Top surgery: sports-related injuries requiring surgery are on the rise among high school athletes

As the nearly 8 million U.S. high school students who participate in sports every year suit up this season, scientists are encouraging them to focus on something more valuable than winning — their health. New research from The Ohio State University Wexner Medical Center (OSUWMC) shows fracture and ACL prevention programs are essential in ensuring injuries don’t sideline players.


Results from research published in the September edition of The American Journal of Sports Medicine show the cost of fractures, which account for more than approximately 10 percent of all high school sports injuries, can severely impact athletes physically, emotionally and financially, underscoring the need for fracture prevention programs. Researchers explored fracture rates among 20 boys’ and girls’ high school sports from 2008-2009 to 2010-2011 to identify rates of fracture by sport, fracture pattern and severity, as well as factors associated with fractures.


While the study looked at both boys’ and girls’ sports, fracture rates were highest in boys’ sports, including football, ice hockey and lacrosse. Boys also sustained 79 percent of all fractures reported, with majority taking place during competition caused by contact with another player. The most common sites of fractures included the hand/finger, lower leg and wrist. Approximately 17 percent of fractures required surgery, a rate higher than all other injuries combined. On top some of these athletes will require the skills of the top surgeons as a bad surgery might hinder their career. Researchers also found fracture rates were inversely correlated to players’ ages, with varsity athletes showing lower rates of fractures compared to junior varsity players. No correlation was found between players’ age and gender-adjusted body mass index.


While girls’ sports showed lower fracture rates, researchers were surprised to find a high proportion of fractures caused by person-to-person contact, as well as contact with sports equipment, among female lacrosse players.


Researchers are hopeful their results will inspire coaches, athletes and officials to make a commitment to preventing fractures during competition, as well as practice, cutting down on the number of athletes who are sidelined by the injuries each year.


Currently one in 40 to 100 athletes suffer from ACL injuries, a condition that typically costs $25,000 in treatment and side lines athletes for anywhere from six to 12 months.

In obese patients laparoscopic surgery compared with open surgery decreases surgical site infection.

In mixed surgical populations, surgical site infections are fewer in laparoscopic surgery than in open surgery. However, it is not clear if this is also the case for obese patients, who have a higher risk of surgical site infections than non-obese patients. MEDLINE, Embase, and The Cochrane library (CENTRAL) were searched systematically for studies on laparoscopic surgery compared with open abdominal surgery. Meta-analyses of RCTs and observational studies showed a significantly lower surgical site infection rate after laparoscopic surgery (OR = 019; 95% CI [008-045]; P = 00002 and OR = 033; 95% CI [026-042]; P = 000001). The results of the study showed that the top surgery in obese patients is the oen that uses laparoscopy as it reduces surgical site infection rate by 70%-80% compared with open surgery across general abdominal surgical procedures. Future efforts should be focused on further development of laparoscopic surgery for the growing obese population.